Elastic member clamps

ABSTRACT

The present application generally relates to orthopedic stabilization systems, and in particular, to systems including clamps. The clamps can be used in addition to or to replace hooks that grasp onto bone members, such as the lamina. One example of such a clamp is an in-line clamp that includes a central opening for receiving a rod member, a first opening for receiving a set screw and a second opening for receiving an elastic member therethrough. Another example of such a clamp is an off-set clamp that includes an upper plate, a bottom plate, and an opening for receiving a rod therein. The upper plate can be separated from the bottom plate to make space for an elastic member that can be secured within the plates. Tulip clamps that utilize one or more elastic members are also provided.

REFERENCE TO RELATED APPLICATIONS

The present application is a continuation of U.S. patent applicationSer. No. 16/018,368, filed on Jun. 26, 2018 (published as U.S. Pat. Pub.No. 2018-0296251), which is a continuation of U.S. patent applicationSer. No. 15/044,251, filed Feb. 16, 2016 (now U.S. Pat. No. 10,034,692),which is a continuation-in-part application of U.S. patent applicationSer. No. 14/053,281, filed Oct. 14, 2013 (now U.S. Pat. No. 9,433,441),which is a continuation-in-part application of U.S. patent applicationSer. No. 13/785,487, filed Mar. 5, 2013 (published as U.S. Pat. Pub. No.2014-0257400). Each of these applications is herebyincorporated-by-reference in its entirety for all purposes.

FIELD OF THE INVENTION

The present application is generally directed to orthopedicstabilization systems, and in particular, to systems including clampsand rod members.

BACKGROUND

Many types of spinal irregularities cause pain, limit range of motion,or injure the nervous system within the spinal column. Theseirregularities can result from, without limitations, trauma, tumor, discdegeneration, and disease. Often, these irregularities are treated byimmobilizing a portion of the spine. This treatment typically involvesaffixing a plurality of screws, hooks and/or clamps to one or morevertebrae and connecting the screws, hooks and/or clamps to an elongaterod that stabilizes members of the spine.

Accordingly, there is a need for improved systems involving screws,hooks and/or clamps for spinal stabilization.

SUMMARY OF THE INVENTION

Various systems, devices and methods related to spinal clamps areprovided. In some embodiments, a spinal system comprises a clamp forreceiving an elongate rod therein, wherein the clamp comprises an inneropening for receiving the elongate rod, a first opening in communicationwith the inner opening, and a second opening in communication with theinner opening; a set screw received in the first opening of the clamp; abushing positioned at a distal end of the set screw; and an elasticmember received in the second opening of the clamp, wherein the elasticmember is configured to be in contact with the elongate rod received inthe clamp.

In other embodiments, a spinal system comprises a clamp for receiving anelongate rod therein, wherein the clamp comprises an inner opening forreceiving the elongate rod, a first opening in communication with theinner opening, and a second opening in communication with the inneropening, wherein the inner opening includes a groove for receiving anelastic member therein; a set screw received in the first opening of theclamp; and an elastic member received in the second opening of theclamp, wherein the elastic member is configured to be in contact withthe elongate rod received in the clamp.

In other embodiments, a spinal system comprises a clamp for receiving anelongate rod therein, wherein the clamp comprises an inner opening forreceiving the elongate rod, a first opening in communication with theinner opening, and a second opening in communication with the inneropening; a set screw received in the first opening of the clamp; abushing in contact with a distal end of the set screw, wherein the setscrew includes a protrusion that extends past a portion of the bushing;and an elastic member received in the second opening of the clamp,wherein the elastic member is configured to be in contact with theelongate rod received in the clamp.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a top perspective view of an in-line clamp according to someembodiments.

FIG. 1B is a side cross-sectional view of the in-line clamp in FIG. 1A.

FIG. 2A is a side cross-sectional view of an alternative in-line clampaccording to some embodiments.

FIG. 2B is a top perspective view of the in-line clamp in FIG. 2A.

FIG. 2C is a side cross-sectional view of the in-line clamp in FIG. 2A.

FIG. 3A is a side cross-sectional view of an alternative in-line clampaccording to some embodiments.

FIG. 3B is a top perspective view of the clamp in FIG. 3A.

FIG. 4A is a top perspective view of an off-set clamp according to someembodiments.

FIG. 4B is a cross-sectional view of the off-set clamp in FIG. 4A.

FIG. 4C is a top perspective view of the off-set clamp in FIG. 4A withan elastic member.

FIG. 4D is a cross-sectional view of the off-set clamp in FIG. 4A withan elastic member.

FIG. 5A is a top perspective view of a tulip clamp according to someembodiments.

FIG. 5B is a side cross-sectional view of the tulip clamp in FIG. 5A.

FIG. 6 is a top perspective view of an integrated holder and tensionerinstrument according to some embodiments.

FIG. 7 is a front cross-sectional view of the integrated holder andtensioner instrument of FIG. 6.

FIG. 8 is a close-up view of a distal portion of the integrated holderand tensioner instrument of FIG. 6.

FIG. 9 is an alternate close-up view of a distal portion of theintegrated holder and tensioner instrument of FIG. 6.

FIG. 10 is a close-up view of a proximal portion of the integratedholder and tensioner instrument of FIG. 6.

FIG. 11 is a close-up view of a distal portion of an alternateintegrated holder and tensioner instrument according to someembodiments.

FIG. 12 is a perspective view of an alternative integrated holder andtensioner instrument.

FIG. 13 is a close-up view of a lower member of the integrated holderand tensioner instrument of FIG. 12.

FIG. 14 is a side view of a lower member of the integrated holder andtensioner instrument of FIG. 12.

FIG. 15 is a side view of a lower member of the integrated holder andtensioner instrument of FIG. 12.

FIG. 16 is a side perspective view of a lower member of the integratedholder and tensioner instrument of FIG. 12.

FIG. 17 is a perspective view of cam locks of the integrated holder andtensioner instrument of FIG. 12.

FIG. 18 is a perspective view of an alternative integrated holder andtensioner instrument.

FIG. 19 is a close-up view of a lower member of the integrated holderand tensioner instrument of FIG. 18.

FIG. 20 is a side view of a lower member of the integrated holder andtensioner instrument of FIG. 18.

FIG. 21 is a side view of a lower member of the integrated holder andtensioner instrument of FIG. 18.

FIG. 22 is a perspective view of cam locks of the integrated holder andtensioner instrument of FIG. 18.

DETAILED DESCRIPTION OF THE ILLUSTRATED EMBODIMENTS

The present disclosure relates to spinal stabilization devices, and inparticular, clamps that utilize elastic members to grasp onto bone. Thevarious clamps can be placed in many positions relative to a bonemember, such as in-line or off-set.

Many spinal components exist to assist in stabilizing spinal members.Among the components that are used are spinal hooks, which can grasponto bone. While spinal hooks are effective and can be less disruptiveand prone to causing injury compared to other components, such asscrews, there is a possibility of the hooks disengaging post surgery,therefore leading to potentially additional surgical intervention torectify.

The present application is directed to spinal stabilization devices thatovercome challenges associated with current spinal devices. Inparticular, it has been found that spinal clamps can be effectivelyprovided that use elastic members, such as elastic bands, to grasp ontobone members. The use of the elastic members advantageously secures theclamps to bone, and reduces the risk of the devices being inadvertentlyremoved from the bone post-surgery.

FIGS. 1A-1C illustrate different views of an in-line clamp utilizing anelastic member, according to some embodiments. The in-line clamp 10comprises a body 12 for receiving a rod member 80 therein. The in-lineclamp 10 is configured to receive an elastic member 60 therethrough tosecure the clamp 10 to a bone member (e.g., a vertebral body).

The in-line clamp 10 includes a body 12 that forms a curved opening ormouth 17 for receiving a rod member 80 therein. As shown in FIG. 1A, insome embodiments, the curved opening 17 of the body 12 is formed facingdownwardly over the rod member 80, such that the rod member 80 isbottom-loaded relative to the clamp 10. Advantageously, the curvedopening 17 is also configured to receive a portion of the elastic member60, which wraps around a vertebral body or bone member. As shown in FIG.1A, the elastic member 60 can be positioned such that a first portion ofthe elastic member 60 is in contact with a first side of the rod member80 and a second portion of the elastic member 60 is in contact with asecond side of the rod member 80 opposite from the first side afterlooping the elastic member around a bone member. In other embodiments,such as shown in FIG. 2A, the elastic member 60 can be configured suchthat portions of the elastic member 60 remain pressed between one-sideof the rod member 80 and an inner wall of the clamp 10, even afterlooping the elastic member 60 around a bone member. One skilled in theart will appreciate that the positioning of the elastic member 60relative to the rod member 80 and the clamp 10 can vary, and that theillustrations shown herein are not meant to limit the positionsavailable for placing the elastic member, but rather show options forplacing the elastic member in the system.

The curved opening 17 for receiving the rod member 80 is formed by innerwalls of the clamp 10. In some embodiments, the curved opening 17 has aradius that can accommodate both the rod 80 and the elongate member 80placed therein. As shown in FIG. 1B, the inner walls of the clamp 10 caninclude a track or groove 32 formed therein that runs along the innerwalls of the clamp 10. The groove 32 advantageously accommodates theelastic member 60 therein. In some embodiments, the groove 32 has awidth that is approximately the same as the width of an elastic member60 positioned therein. With the addition of the groove 32, the clamp 10,rod member 80 and elastic member 60 can be held together, even beforetightening the set screw 25 (as discussed below). In some embodiments,the groove 32 runs substantially or completely along the inner walls ofthe clamp 10.

The curved opening 17 is in communication with a first opening 14 and asecond opening 16, each of which extends through the body 12 of theclamp 10. The first opening 14, which runs diagonally relative to avertical mid-plane of the device, is configured to receive a threadedset screw 25 therein. When the rod member 80 and elastic member 60 havebeen placed in a desired position within the mouth of the clamp 10, theset screw 25 can be downwardly threaded to apply a compression force onthe rod member 80 and elastic member 60 to securely capture the memberswithin the clamp 10.

In some embodiments, a separate bushing 28 can be attached to a distalend of the set screw 25, as shown in FIGS. 1A and 1B. The bushing 28advantageously provides an intermediary contact surface between the setscrew 25 and the elastic member 60, thereby preventing the elasticmember 60 from fraying or tearing from the contacting the surface of theset screw 25. As shown in FIG. 1B, the bushing 28 has a curved contactsurface 29 that conforms to the shape of the rod member 80 and elasticmember 60 positioned in the mouth of the clamp. The curved contactsurface 29 advantageously serves as a pressure distribution surface thatcomfortably distributes pressure around the rod and elastic member 60 asthe threaded set screw 25 is downwardly threaded. In other embodiments,the contact surface 29 of the bushing 28 is partially straight. Whilethe set screw 25 and bushing 28 are illustrated as separate components,in other embodiments, the two components are integrated components. Theset screw 25 and bushing 28 can be molded together, or can be formed ofa monolithic member. In some embodiments, the set screw 25 and thebushing 28 are formed of different materials, while in otherembodiments, the set screw 25 and the bushing 28 are formed of the samematerials. In some embodiments, the set screw 25 and/or bushing 28 canbe formed of different biocompatible metals, such as stainless steel,titanium or cobalt-chrome.

The second opening 16, which runs generally through a vertical mid-planeof the device, is configured to receive one or more elastic members 60therethrough. As shown in FIG. 1A, this central opening 16 is wideenough to receive two ends or portions of an elastic member 60 that hasbeen looped around a vertebral body. One skilled in the art willappreciate that the positioning of the first and second openings 14 and16 should not be limited. For example, in alternative embodiments, thepositions of the first opening 14 and the second opening 16 can beswitched. Alternatively, in other embodiments, the second opening 16 forreceiving the ends of the elastic members 60 can be moved away from thevertical mid-plane of the device.

In some embodiments, the elastic member 60 can be a cable. Preferably,the elastic member 60 is a wide elastic band 60. The use of a wideelastic band 60 can advantageously reduce the risk of damage to tissuelacerations or injury. In some embodiments, the elastic band 60 isbetween 2 and 8 mm, or greater than 4 mm. In some embodiments, the bandis composed of a polymer, such as PET. To ensure that the clamp 10remains secured to a bone member via the elastic band 60, a tensionercan be included as part of the system to make sure that the bands are inproper tension and tightness.

The in-line clamp 10 can be used as follows. In some embodiments, theelastic member 60 (e.g., band) can first be introduced to the clamp 10without the rod 80 inserted therein. The elastic member 60 can bepositioned along and within the single groove 32 that extends along aninner surface of the clamp, which advantageously helps to center theelastic member 60. Both ends of the elastic member 60 can extend throughthe second hole 16, thereby forming a loop at the bottom of the elasticmember 60. The loop of the elastic member 60 can be wrapped around aportion of a spine (not shown), such as a lamina. With the elasticmember 60 in place, a rod member 80 can be received through the bottomopening 17 of the clamp 10. Once the rod member 80 is pushed through thebottom opening 17 of the clamp 10 and against the inner walls of theclamp, the rod member 80 is provisionally held in the clamp 10. At thistime, the rod member 80 is advantageously free to translate along thedirection of its longitudinal axis.

With the rod member 80 in the clamp, a tensioner can be used to tensionthe elastic member 60, thereby pulling the spine to the rod member 80 inorder to correct a deformity. When adequate correction is obtained, theset screw 25 can be downwardly threaded to tighten and securely capturethe elastic member 60 and rod member 80. The bushing 28, which serves aseither a floating piece that is separate from the set screw 25 or anintegrally formed piece with the set screw 25, is positioned at thedistal end of the set screw 25 to distribute the tightening load of theset screw 25 uniformly across the elastic member 60 and the rod member80. As the set screw 25 is downwardly threaded, the set screw 25compresses against the elastic member 60 and rod member 80, therebysecuring the system. At this time, the rod member 80 is locked in placeand is no longer free to translate.

FIGS. 2A-2C illustrate different views of an alternate in-line clamp 10according to some embodiments. The in-line clamp 10 in these figuresdiffers from the clamp in FIGS. 1A and 1B in that it has a first opening14, a second opening 16 and an additional third opening 18 that extendsthrough the body of the clamp. As shown best in FIG. 2A, the additionalthird opening 18 is configured to receive two portions or strands of alooped elastic member 60, which also extend into the second opening 16.In addition, while the curved opening 17 opens downward such that therod member 80 remains bottom-loaded, the curved opening 17 is now morediametrically positioned relative to a vertical mid-plane of the device.

In this embodiment, the elastic member 60 passes through both the secondopening 16 and the third opening 18. A loop is formed by the elasticmember 60 closer to the third opening 18 and is capable of wrappingaround a bone member. In the present embodiments, when a rod member 80is positioned in the curved opening 17 of the clamp 10, the elasticmember 60 is kept on one side of the rod member 80. In other words, theelastic member 60 is positioned between the rod member 80 and the innerwalls of the clamp 10, as shown in FIG. 2A. The addition of the thirdopening 18 thus provides additional ways to accommodate the elasticmember 60 relative to the rod member 80 and the clamp 10.

FIGS. 3A and 3B illustrate different views of an alternative in-lineclamp 10 according to some embodiments. The in-line clamp 10 in thesefigures differs from the clamp in FIGS. 1A and 1B in that it has a firstopening 14, a second opening 16, additional third and fourth openings18, 19, and a unique set screw 25 having an extension member 26. Boththe third opening 18 and the fourth opening 19 are in communication withthe opening 17 for receiving a rod member, and are positioned near alower portion of the clamp 10.

The clamp 10 is configured to receive an elastic member 60 therethrough.In some embodiments, a first end of the elastic member 60 can extendthrough the third opening 18 while a second end of the elastic member 60can extend through the fourth opening 19, such that both the first andsecond ends of the elastic member 60 meet and pass through the secondopening 16. A loop is formed at the bottom of the elastic member 60 toreceive a bone member. In alternate embodiments, a first end of theelastic member 60 and a second end of the elastic member 60 can passthrough the third opening 18 and through the second opening 16 (similarto as shown in FIG. 2A). In yet further alternate embodiments, a firstend of the elastic member 60 and a second end of the elastic member 60can pass through the fourth opening 19 and through the second opening16. With the latter two options, the elastic member 60 can be kept togenerally one side of a rod member 80 inserted into the clamp 10.Accordingly, with the addition of the third opening 14 and the fourthopening 19, this advantageously provides a number of different optionsfor securing the clamp to bone.

The clamp 10 includes a unique set screw 25 having an extension member26 formed on a distal end thereof. As shown in FIG. 3A, the extensionmember 26 is a shaped protrusion that can extend through the bushing 28.When the elastic member 60 passes along the inner walls near the bushing28 (e.g., while entering or exiting the fourth opening 19), theextension member 26 of the set screw 25 is advantageously configured tocontact a portion of the elastic member 60 positioned therein. Thisadditional contact provided by the extension member 26 of the set screw25 helps to advantageously stabilize the elastic member 60 and, alongwith the bushing 28, helps to distribute the compressive load thatoccurs during downward threading of the screw 25. In some embodiments,the extension member 26 comprises a blunt tip to reduce the likelihoodof fraying of the elastic member 60.

FIGS. 4A-4D illustrate different views of an off-set clamp according tosome embodiments. The off-set clamp 100 is configured to receive anelastic member 60 (e.g., through slot or opening 116) on one side of theclamp 100, and a rod member 80 on an opposite side of the clamp 100. Theclamp 100 comprises an upper plate 110 having a first opening 114 and asecond opening 116 and a lower plate 120. The first opening 114 isconfigured to receive a set screw 125 that extends through the upperplate 110 and the lower plate 120. The second opening 116 is configuredto receive an elastic member 60 as discussed below.

As shown in FIG. 4B, the upper plate 110 can be physically separated andlifted away from the lower plate 120, thereby providing a space 130 forreceiving one or more portions of an elastic member 60 therethrough. Insome embodiments, the upper plate 110 can translate both vertically androtationally relative to the lower plate 120, thereby providing a largeenough space 130 (shown in FIG. 4B) for receiving an elastic member 60.The elastic member 60 can form a loop that extends around a bone member,with a first portion of the elastic member 60 in contact with a firstlower surface 121 of the lower plate 120 and a second portion of theelastic member 60 in contact with a second lower surface (not shown) onthe opposite side of the lower plate 120. The elastic member'strajectory is shown in FIGS. 4C and 4D. In some embodiments, the lowersurfaces 121 of the lower plate 120 can comprise an overhang forreceiving the elastic member 60 to prevent the elastic member fromsliding off of the assembly. With the portions of the elastic member 60in contact with the lower portions of the lower plate 120, first andsecond ends of the elastic member 60 can be inserted through the space130 (shown in FIG. 4B) created when the upper plate 110 is separatedfrom the lower plate 120. The first and second ends of the elasticmember 60 can then be inserted through the slot 116 formed in the upperplate 110.

With the elastic member 60 in place such that it is looped around a bonemember and such that both of its ends pass through the slot 116, theupper plate 110 can be brought downwardly onto the lower plate 120,thereby securing the elastic member 60 therein. To ensure that the upperplate 110 is secure to the lower plate 120, the set screw 125 can bedownwardly threaded, thereby compressively bringing the upper plate 110into a secure relationship with the lower plate 120. Advantageously, thedownward threading of the set screw 125 will also secure a rod member 80received in the rod opening 117 formed on the opposite ends of the clamp100. In other words, in some embodiments, the downward threading of theset screw 125 will both secure the elastic member 60 within the upperand lower plates on one side of the clamp 100, and simultaneously securean off-set rod member 80 that is positioned in a rod opening 117 on anopposite side of the clamp 100.

When the upper plate 110 is removed from the lower plate 120 (e.g.,vertically and/or rotationally) such that an elastic member 60 can bereceived in the space 130, the clamp 100 can be considered to be in an“open” or “unlocked” configuration. When the upper plate 110 isdownwardly secured to the lower plate 120 (e.g., via the set screw 125)such that the elastic member 60 is secured within the upper plate 110and the lower plate 120, the clamp 100 can be considered to be in a“closed” or “locked” configuration.

The off-set clamp 100 can be used as follows. When the clamp is ready toreceive the elastic member 60 and rod member 80, the upper plate 110 canbe raised and rotated slightly from the lower plate 120 to provide room(e.g., space 130) for inserting an elastic member (e.g., band) 60between the upper plate 110 and the lower plate 120. The elastic membercan wrap around a spinal portion (e.g., a lamina), and can extend alongthe outer, bottom side walls 121 of the lower plate 120. The bottom sidewalls 121 of the lower plate 120 can include an overhang to prevent theelastic member 60 from sliding off the clamp 100. Both ends of theelastic member 60 can continue to extend through the slot 116 formed inthe upper plate 110. On the opposite side of the clamp 100, a rod member80 can be received between the upper plate 110 and the lower plate 120.Before tightening the set screw 125 that extends between the upper plate110 and the lower plate 120, the rod member 80 is provisionally held inthe clamp 100 and is advantageously free to translate along itslongitudinal axis. With the elastic member 60 wrapped around a bonemember and the clamp 100, and the rod member 80 received on the oppositeend, the set screw 125 can be tightened such that the clamp 100 clampsdown on both the elastic member 60 and rod member 80. Thisadvantageously secures both the elastic member 60 between the upperplate 110 and lower plate 120 on one side of the clamp 100, and theoff-set rod member 80 within the rod opening 117 on the opposite side ofthe clamp 100.

FIGS. 5A and 5B illustrate different views of a tulip clamp according tosome embodiments. The tulip clamp 200 comprises a first arm 202 and anopposing second arm 204 that join at a base, thereby forming a U-shapedchannel for receiving a rod member 80. The first arm 202 comprises afirst angled slot or opening 214 for receiving a first end of an elasticmember 60 therethrough and the second arm 204 comprises a second angledslot or opening 216 for receiving a second end of the elastic member 60therethrough. The bottom of the elastic member 60 can form a loop thatpasses through a third opening 218 formed at the base of the tulipclamp. The loop is capable of looping around a bone member, such as alamina.

Advantageously, as shown in FIG. 5B, the third opening 218 of the tulipclamp 200 has slanted inner walls. These inner walls advantageouslyserve as a guide for first and second portions of the elastic member 60prior to the elastic member 60 opening into a loop below the clamp 200.In some embodiments, the third opening 218 has a width that is greaterthan a maximum width of the first opening 214 and/or the second opening216.

The tulip clamp 200 can be used as follows. An elastic member 60 canfirst be inserted through the tulip clamp 200 by passing first andsecond ends of the elastic member 60 through the base opening 218. Thefirst end of the elastic member 60 can pass through the angled slot oropening 214, while the second of the elastic member 60 can pass throughthe angled slot or opening 216. The bottom of the elastic member 60forms a loop that can be wrapped around a spinal portion, such as alamina. With the elastic member 60 in place, a rod member 80 can beintroduced into the U-shaped channel of the tulip head, such that theelastic member 60 contacts the rod member 80 on two sides. After the rodmember 80 is delivered downwardly into the tulip head, a locking capincluding a set screw (not shown) can be delivered onto the rod member80. In some embodiments, the locking cap can rest in locking cap slots231 found in the arms. In some embodiments, the set screw is threadedand interacts with threads on the arms of the tulip clamp. In otherembodiments, in lieu of a set screw and locking cap, a singlenon-threaded locking cap can be provided. Prior to locking the setscrew, the rod member 80 can be provisionally captured such that it isadvantageously free to move along its longitudinal axis. With theelastic member 60 and rod member 80 in place, a tensioner can tensionthe band to pull the spine up to the rod member 80 to correct adeformity. Once the deformity is corrected by tensioning the band, theset screw in the locking cap can be downwardly tightened to secure therod member 80 and elastic member 60 within the tulip clamp 200.

The clamps discussed above can be accompanied by one or more instrumentsto facilitate insertion and implantation. For example, in order toproperly install a clamp, a tensioner may be used to help tension theelastic member while it is wrapped around a bony structure. Thetensioner can hold the elastic member in a corrected position until theset screw of the clamp is finally tightened to securely hold theconstruct. Accordingly, the clamps can be accompanied by at least twoinstruments—a holder instrument to facilitate insertion and delivery ofthe clamp, and a tensioner instrument to hold the elastic band intension prior to securing the construct.

Alternatively, a novel integrated holder and tensioner instrument can beprovided to facilitate insertion and implantation of a clampingassembly. FIG. 6 is a top perspective view of an integrated holder andtensioner instrument according to some embodiments. By providing anintegrated holder and tensioner, the instrument advantageously reducesthe need for multiple instruments, and provides a secure means forinstalling the clamp and elastic member assembly securely.

As shown in FIG. 6, the integrated holder and tensioner instrument 300comprises a distal portion comprising a clamp holder 310 for holding aclamp. The clamp holder 310 is operatively connected to an outer sleeve320 which includes one or more slots 322 through which an elastic membercan pass therethrough. Adjacent to a proximal portion of the outersleeve 320 is an elastic member lock base or carriage 340 and an elasticmember lock 330, the latter of which is also designed to receive anelastic member therethrough. The integrated instrument 300 furtherincludes a tensioner driver 350 for tensioning an elastic member and aclamp holder handle 300 for opening and closing the clamp holder 310.Each of these components is discussed in greater detail below.

In some embodiments, a distal portion of the instrument 300 comprises aclamp holder 310 for receiving a clamp therein. The clamp holder 310comprises a pair of fingers or tips 312 that can flex open to receive aclamp therein. The tips 312 are capable of flexing via flexible slits orcuts 314, as shown in FIG. 7. The clamp holder 310 can have twoconfigurations: an “open” configuration, whereby it is capable ofprovisionally and gently holding a clamp therein, and a “closed”configuration, whereby it grips the clamp therein securely and tightly.The clamp holder 310 can be in the open configuration when it firstgrasps a clamp 10 therein. Once the clamp 10 is provisionally capturedin the clamp holder 310, the clamp holder 310 can be placed in a closedconfiguration to tighten the grip on the clamp 10. This can beaccomplished by rotating the clamp holder handle 360, which causes theouter sleeve 320 to translate downwardly onto the clamp holder 310,thereby preventing the tips 312 of the clamp holder 310 from flexingopen.

The outer sleeve 320 comprises an elongate body that is operablyattached to the clamp holder 310. A distal portion of the outer sleeve320 is configured to include a pair of elongated slots 322. Theelongated slots 322 are configured to receive the ends of the elasticmember after the elastic member has been passed through the clamp (asshown in FIG. 1A) and into the distal end of the outer sleeve 320. Eachend of the elastic member can pass through a slot 322 formed in theouter sleeve and can extend along the length of the outer sleeve,whereby they can be received in the elastic member locks 330.

The elastic member locks 330 comprise a pair of “wing” shaped membersdesigned to receive an elastic member therein. In some embodiments, eachof the elastic member locks 330 comprises an opening or slit 332 forreceiving and capturing an end of the elastic member. As the elasticmember passes through an elastic member lock 330, the elastic memberlock 330 captures and secures the elastic member via a one-way,unidirectional auto-tightening mechanism, thereby preventing the elasticmember from backing out from the elastic member lock 330. In otherwords, an elastic member that passes through the elastic member lock 330can be pulled in tension, without worrying about backing out of theelastic member. The one-way, auto-tightening mechanism can comprisedifferent types of mechanisms, including cam, grooved, flat, and/orrounded surfaces whereby once engaged, they prevent sliding of theelastic member within the lock 330. When desired, an elastic member canbe released from an elastic member lock 330 by pressing the elasticmember lock 330 downwardly, thereby actuating a release function.

The elastic member locks 330 are positioned adjacent to the elasticmember lock base or carriage 340 and the tensioner driver 350, whichwork in conjunction to place the ends of the elastic member in tension.By rotating the tensioner driver 350, this causes the elastic memberlock base or carriage 340 to translate along the longitudinal axis ofthe outer sleeve in a proximal direction away from the clamp 10. Thismovement of the elastic member lock base 340 pulls on the elasticmember, thereby placing the ends of the elastic member (which areconstrained to the elastic member locks 330) in greater tension.

In addition to these features, the integrated instrument 300 includes aclamp holder handle 360 positioned at a proximal portion of theinstrument 300. As discussed earlier, the clamp holder handle 360 iscapable of actuating the outer sleeve 320, thereby causing the clampholder 310 to be in an “open” or “closed” position.

Methods for using the integrated holder and tensioning instrument 300are now described. In some embodiments, a surgeon would select a clamp10 to be inserted into a patient. The surgeon can then engage theinstrument 300 to the clamp 10 via the clamp holder 310. The clampholder 310 is in an “open” configuration, and is only provisionallyengaged with the clamp 300. After provisionally engaging the clampholder 310 to the clamp 10, an elastic member (e.g., a band) can bepassed through the clamp 10 and out through the clamp holder 310 and theslots 322 of the outer sleeve 320. In addition to retaining the clamp10, the clamp holder 310 can be used to provisionally retain a rodmember that is forced into the clamp 10. With the rod and elastic memberprovisionally retained within the clamp 10 and clamp holder 310, thesurgeon can rotate the clamp holder handle 360 to place the clamp holder310 in a “locked” configuration, thereby tightening the grip on theclamp 10.

At this time, the ends of the elastic member can be passed through theelastic member locks 330, thereby securely capturing the ends. Once theends of the elastic member are captured in the elastic member locks 330,the tensioner driver 350 can be rotated to place further tension on theelastic member's ends. Once the elastic member has been placed in adesired amount of tension, the surgeon can use a hex driver to tightenthe set screw 25 of the clamp 10 to thereby secure the clamp member, rodmember and elastic member. As the clamp 10 and its associated elasticmember are now assembled, the surgeon can either (i) unlock the elasticmember locks 330 to slide the elastic member ends out or (ii) cut theelastic member on either side without unlocking the elastic memberlocks. The clamp holder 360 can then be rotated to disengage theinstrument 300 from the installed clamp 10, thereby allowing theinstrument 300 to be removed from the assembled clamp construct in thepatient. Optionally, as the ends of the elastic member are loose, thesurgeon may choose to cauterize the ends to prevent fraying of the looseends.

In addition to the components discussed above, the integrated holder andtensioner instrument 300 can further include other components. In someembodiments, the tensioner instrument 300 can be accompanied by acounter torque device (not shown) that can be attached to the countertorque attachment surface 370 on the elastic member base 340. Thecounter torque device helps to limit rotation to only those componentnecessary when rotating the tensioner driver. In addition, the tensionerinstrument 300 can also be accompanied by a secondary handle thatattaches to the clamp handle 360 to limit or indicate the amount oftorque being applied, thereby advantageously preventing over-tensioningof the elastic member.

FIG. 7 is a front cross-sectional view of the integrated holder andtensioner instrument of FIG. 6. From this view, one can see thecross-section of the clamp holder 310, including the flexible cuts orslits 314 that enable flexion of the clamp holder tips 312.

FIG. 8 is a close-up view of a distal portion of the integrated holderand tensioner instrument of FIG. 6. From this view, one can see theupper opening 16 in the clamp 10 through which the ends of the elasticmember can pass before passing through the slots 322 in the outer sleeve320.

FIG. 9 is an alternate close-up view of a distal portion of theintegrated holder and tensioner instrument of FIG. 6. From this view,one can see a rod member 80 that is provisionally captured in the clamp10 via the clamp holder 310. To tighten the grip on the rod member 80and clamp 10, the outer sleeve 320 can be translated downwardly tocompress the flexible tips of the clamp holder 310, thereby causing theclamp holder 310 to be in a “closed” tight position.

FIG. 10 is a close-up view of a proximal portion of the integratedholder and tensioner instrument of FIG. 6. From this view, one can seethe opening or slit 332 formed in each of the elastic member locks 330,through which an elastic member can pass through. The slit 332 serves asa contact or locking surface of the elastic member, which is configuredto pass through each of the elastic member locks 330 prior to tensioningthe elastic member.

An alternate design of an integrated holder and tensioner instrument isnow described. FIG. 11 is a close-up view of a distal portion of analternate integrated holder and tensioner instrument according to someembodiments. The instrument in FIG. 11 shares many features with theinstrument in FIG. 6, including a clamp holder, an outer sleeve, elasticmember locks, an elastic member base, a tensioner driver, and a clampholder handle. However, in contrast to the instrument in FIG. 6, theinstrument in FIG. 11 comprises a clamp holder 310 having a pair ofhinged tips 312. The hinges 317 allow the tips 312 to open and close ona clamp and/or rod member similarly to the instrument in FIG. 6. Infurther contrast to the instrument in FIG. 6, the instrument in FIG. 11can also include one or more teeth for securing the clamp holder 310 tothe outer sleeve 320.

Additional integrated holder and tensioner instruments are shown inFIGS. 12-22. The instruments 400, 500 shown in these embodiments includea number of distinct advantages. In particular, the instruments 400, 500allow for elastic members to be advantageously side-loaded into theinstruments, which allows for ease of engagement between the elasticmembers and their respective instruments. In addition, the instruments400, 500 advantageously have lower members 402, 502 that are capable ofseparation from respective upper members 404, 504. This allows forgreater visibility during the surgical procedure, as will be discussedin greater detail below.

FIG. 12 is a perspective view of an alternative integrated holder andtensioner instrument in accordance with some embodiments. The instrument400 comprises a lower member 402 and a separable upper member 404. Thelower member 402 comprises a bottom cam lock 430 having a side opening431 for receiving an elastic member therethrough. An upper member 404 isattachable to the lower member 402. The upper member 404 furtherincludes a top cam lock 460 having a side opening 461 for receiving theelastic member therethrough. The top cam lock 460 can be attached to amoveable elastic member lock base or carriage 440. Translation of thecarriage 440 (e.g., via a tensioner driver 450) in an upward directioncauses the tension on the elastic member to increase, while translationof the carriage 440 in a lower direction reduces tension on the elasticmember.

Advantageously, the instrument 400 can allow for sequential reduction ofthe spine by providing a low profile lower member 402 that can retaintension on the elastic member. The instrument 400 is advantageouslydesigned such that the lower member 402 can be attached to a bone memberwithout the upper member 404 attached thereto. The lower member 402 canthen receive a portion of the elastic member therethrough with minimalobstruction. The lower member 402 is designed to advantageously retaintension on the elastic member, while maintaining a low profile prior toattachment of the upper member 404. When the elastic member is ready tobe tensioned further, the upper member 404 can simply be fitted onto thelower member 402 (e.g., via a snapfit or connection), and the elasticmember can then be received through the top cam lock 460. The tensionerdriver 450 can then be rotated, thereby causing upward translation ofthe carriage 440 and top cam lock 460. This increases the tension in theelastic member.

As shown in FIG. 12, the lower member 402 comprises a shaft 409 having adistal end that is operably attached to a clamp holder 410. A sleeve 420extends around the shaft 409. The clamp holder 410 comprises at leasttwo sets of fingers or tips 412 that are configured to grip a clamp 10therein. The clamp holder 410 can comprise proximal nubs or hinges 411that interact with the sleeve 420, as will be discussed further below.The clamp holder 410 is configured to hold both a clamp 10 and a rodmember 80 within the clamp (as shown in FIGS. 14 and 15).

The clamp holder 410 is capable of provisionally retaining a clamp 10therein simply by applying a downward force on the clamp 10. The shaft409 of the lower member 402 comprises a cut portion that extends along alongitudinal axis of the lower member 402. In particular, the shaft 409comprises a circular or rounded flex cut 428 and an elongated cut 429.These cuts 428, 429 advantageously allow the fingers 412 of the clampholder 410 to spread open, thereby retaining the clamp 10 therein uponapplication of downward force to the clamp 10.

The clamp holder 410 is also capable of receiving and retaining a rodmember 80 within the clamp 10. To retain the rod member 80, the fingers412 are first moved into a spread “open” configuration, as shown in FIG.14. To move the fingers into the open configuration, the sleeve 420 canbe pulled upward via a pair of wings 422. In some embodiments, thesleeve 420 is spring-loaded. As the sleeve 420 is pulled upward, thedistal end of the sleeve 420 is removed from engagement with theproximal nubs 411 of the clamp holder 410, which thereby allows thefingers 412 to spread into the open configuration. With the fingers 412in the open configuration, a rod member 80 can be delivered into theclamp holder 410. Once the rod member 80 is delivered therein, the wings422 can be released. Releasing the wings 422 causes the spring-loadedsleeve 420 to return to its original configuration, whereby its distalend is in engagement with the proximal nubs 411 of the clamp holder 410(as shown in FIG. 12). This moves the fingers 412 into a “closed”configuration, as shown in FIG. 15, which thereby encloses the rodmember 80 therein.

The clamp 10 that is retained within the clamp holder 410 can include anelastic member. The elastic member can extend through a side-loadedopening 431 of the bottom cam lock 430, thereby advantageously placingthe elastic member in tension. In some embodiments, the bottom cam lock430 is spring loaded. As the elastic member is extended through thebottom cam lock 430, the spring loaded feature allows the elastic memberto be retained within the bottom cam lock 430. To release the elasticmember from the bottom cam lock 430, the bottom cam lock 430 comprises arelease latch 432. Movement of the release latch 432 enables controlledmovement of the elastic member within the bottom cam lock 430 asdesired.

The lower member 402 is advantageously capable of attachment to bonemember without the upper member 404 attached thereto. This allows forenhanced visibility of the surgical site by providing an instrument thatis less obstructive.

As shown in FIG. 12, the upper member 404 comprises a distal shaft 442,an outer shaft 443 that extends around the distal shaft 442, an elasticmember lock base or carriage 440 attached to the distal shaft 442, atensioner driver 450 for translating the carriage 440, and a threadedshaft 480 extending through the tensioner driver 450.

The distal shaft 442 of the upper member 404 comprises a cylindricalshaft that is sized and configured to be received in an opening of thelower member 402. In some embodiments, the distal shaft 442 comprises asmooth outer surface. The distal end of the distal shaft 442 comprisesone or more members that allow for a quick connection with the lowermember 402 (e.g., via a snap fit).

The outer shaft 443 of the upper member 404 comprises a cylindricalshaft that is sized and configured to extend around the distal shaft442. In some embodiments, the outer shaft 443 comprises a shaft releasebutton 444. When the release button 444 is pressed down, this disengagesthe distal shaft 442 from the lower member 402, thereby allowing forremoval of the upper member 404 from the lower member 402.

The carriage 440 of the upper member 404 is attached to a proximal endof the outer shaft 443. A top cam lock 460 extends from the carriage440. The top cam lock 460 comprises a side-loaded opening 461 thatallows an elastic member to be side-loaded therein. In some embodiments,an elastic member can be extended through the bottom cam lock 430 andinto the top cam lock 460, whereby it can be further tensioned. The topcam lock 460 further comprises a release latch 462. Movement of therelease latch 462 releases the elastic member if desired, therebyreducing tension on the elastic member. In some embodiments, the top camlock 460 is spring loaded, such that upon release of the top cam lock460, the top cam lock 460 will go back to its original position andretain the elastic member therein. In addition, the carriage 440 of theupper member 404 comprises a counter torque attachment surface 470 whichcan be gripped by a counter torque device. The counter torque devicehelps to limit rotation to only those components necessary when rotatingthe tensioner driver. In some embodiments, the carriage 440 is capableof translation via the tensioner driver 450, thereby increasing thetension on the elastic member.

The tensioner driver 450 of the upper member 404 comprises a cylindricalmember that is attached to a proximal end of the carriage 440. Thetensioner driver 450 can comprise a base portion that is received in acut out portion 441 of the carriage 440, thereby retaining the tensionerdriver 450 to the carriage 440. The tensioner driver 450 includesinternal threads that are configured to engage external threads of thethreaded shaft 480. Rotation of the tensioner driver 450 in a firstdirection causes the tensioner driver 450 to rotate upwardly along thethreaded shaft 480. As the tensioner driver 450 is attached to thecarriage 440, the carriage 440 also translates upwardly, therebyincreasing tension on the elastic member attached to the carriage 440.Rotation of the tensioner driver 450 in a second direction causes thetensioner driver 450 to rotate downwardly along the threaded shaft 480.This causes the carriage 440 to translate downwardly, thereby reducingtension on the elastic member attached to the carriage 440. In someembodiments, the tensioner driver 450 comprises a hex knob.

The threaded shaft 480 of the upper member 404 comprises externalthreads that engage internal threads of the tensioner driver 450. Insome embodiments, the threaded shaft 480 comprises a proximal cap 484.Advantageously, the proximal cap 484 serves as a stop that prevents thetensioner driver 450 from going past the cap, thereby reducing the riskof the tensioner driver 450 from falling off the threaded shaft 480.

The method of using the instrument 400 is as follows. In someembodiments, the lower member 402 is delivered to receive a clamp 10,which can further receive a rod member 80 therein. An elastic member orband that extends through the clamp 10 can be pulled through a sideopening or slot 431 of the bottom cam lock 430, thereby placing theelastic member in tension. The upper member 404 can then be deliveredinto attachment with the lower member 402, whereby it can be attachedvia a quick connection (e.g., a snap fit). The elastic member can thenbe pulled through a side opening or slot 461 of the top cam lock 460,whereby it can be retained in further tension. To increase tension onthe elastic member, the tensioner driver 450 can be rotated, therebycausing upward translation of the carriage 440 upon which the top camlock 460 resides. As the carriage 440 is drawn upwardly, this increasesthe tension on the elastic member. When the elastic member has achievedits desired tension, a set screw 25 (shown in FIG. 1A) can be downwardlythreaded onto the elastic member, thereby securing the clamp 10 to bone.The instrument 400 can then be removed from the clamp. First, the uppermember 404 can be released from the lower member 402 by pressing therelease button 444. Second, the lower member 402 can be released fromthe clamp 10 by pulling upwardly on the wings 422 of the sleeve 420.This causes the fingers 412 to open, which thereby allows the clamp 10to disengage from the instrument 400 if desired. In some embodiments,loose ends of the elastic member can be cut while attached to theinstrument 400. In other embodiments, loose ends of the elastic memberare cut after detachment of the instrument 400 from the elastic member.Any remaining loose ends of the elastic member can be glued, singed, orfurther cut if desired. At this time, the clamp 10 is securely retainedon a bone member.

FIG. 13 is a close-up view of a lower member of the integrated holderand tensioner instrument of FIG. 12. From this view, one can see theshaft 409, as well as the rounded flex cut 428 and elongated flex cut429 formed therein. The flex cuts 428, 429 advantageously help theinstrument to retain a clamp 10, simply by downward force onto the clamp10.

FIG. 14 is a side view of a lower member of the integrated holder andtensioner instrument of FIG. 12. From this view, one can see the fingers412 in a “open” configuration, whereby a rod member 80 can be receivedtherein. The fingers 412 include at least one hinged portion 413,whereby in the open configuration, the hinged portion 413 is away fromthe opposing finger, thereby providing room to receive the rod member80. To maintain the fingers 412 in the open configuration, the sleeve420 is pulled upwardly via its wings 422.

FIG. 15 is a side view of a lower member of the integrated holder andtensioner instrument of FIG. 12. From this view, one can see the fingers412 in a “closed” configuration whereby a rod member 80 is securedtherein. In the closed configuration, the hinged portion 413 is nearerto the opposing finger, thereby trapping the rod member 80 within theclamp 10. To place the fingers 412 in the closed configuration, asurgeon simply needs to release the wings 422. The spring-loaded actionof the sleeve 420 will cause the sleeve to go back to its originallocation, such that the fingers 412 are placed in the closedconfiguration.

FIG. 16 is a side perspective view of a lower member of the integratedholder and tensioner instrument of FIG. 12. From this view, one can seethe bottom cam lock 430 close up. The bottom cam lock 430 includes aside-loaded opening or slot 431 for easily delivering an elastic membertherein.

FIG. 17 is a perspective view of cam locks of the integrated holder andtensioner instrument of FIG. 12. From this view, one can see the bottomcam lock 430, the top cam lock 460 and the elastic member 60 thatextends between the two cam locks. Advantageously, the elastic member 60is side-loaded into each of the bottom cam lock 430 and the top cam lock460, thereby making it easier to retain the elastic member 60 therein.

FIG. 18 is a perspective view of an alternative integrated holder andtensioner instrument. The instrument 500 comprises a number of similarfeatures as the embodiment in FIG. 12, including a lower member 502having distal fingers or tips 512 and an upper member 504 separable fromthe lower member 502. The lower member 502 comprises a bottom cam lock530, while the upper member 504 comprises a top cam lock 560, each ofwhich is configured to have an opening or slot 531, 561 foradvantageously side loading an elastic member. In some embodiments, theopenings 531, 561 are inline and preserve the visibility of the surgicalsite during use. As shown in FIG. 18, the instrument 500 includes analternate sleeve 511 for placing the fingers 512 in an open or closedconfiguration, as will be discussed in more detail below.

The instrument 500 comprises a lower member 502 including a shaft 509having a rounded flex cut 528 and an elongated flex cut 529. A clampholder 510 is positioned at a distal end of the shaft 509. The clampholder 510 comprises sets of fingers or tips 512 designed to retain aclamp 10 and/or a rod member 80 therein. A spring-loaded sleeve 511extends over the shaft 509 and is designed to place the fingers 512 in a“closed” or “open” configuration. In its natural state, the sleeve 511extends distally around fingers 512, thereby placing the fingers 512 ina closed configuration. To put the fingers 512 in an open configurationwhereby they can receive a clamp 10 and/or rod member 80 therein, asleeve release button 517 can pushed, thereby freeing the sleeve 511such that it can moved along a longitudinal path. In some embodiments,the sleeve 511 is capable of being moved along a longitudinal pathsimply by pushing the sleeve release button 517. With the sleeve releasebutton 517 pushed, the sleeve 511 can be moved upwardly or downwardly,thereby placing the fingers 512 in a “closed” or “open” configuration asdesired.

In addition, the lower member 502 further comprises a bottom cam lock530 having an opening or slot 531 that allows for side-loading of anelastic member. In some embodiments, the bottom cam lock 530 isspring-loaded. To release the elastic member, a release latch mechanism532 is provided. The release latch mechanism 532 allows for the releaseof an elastic member once it has been received through the side opening531.

The instrument 500 further comprises an upper member 504 including adistal shaft 542, a lock base or carriage 540 attached to the proximalend of the distal shaft 542, a tensioner driver 550 attached to thecarriage 540 and a threaded shaft 580 extending through the carriage540. Advantageously, in some embodiments, the upper member 504 isseparable from the lower member 502. This way, the lower member 502 canbe inserted near a surgical site without the upper member 504, and anelastic member can be received and tensioned via the lower member 502without obstruction from the upper member 504.

The distal shaft 542 of the upper member 504 comprises a cylindricalshaft that is sized and configured to be received in an opening of thelower member 502. In some embodiments, the distal shaft 542 comprises asmooth outer surface. The distal end of the distal shaft 542 comprisesone or more members that allow for a quick connection with the lowermember 502 (e.g., via a snap fit).

The carriage 540 of the upper member 504 is attached to a proximal endof the distal shaft 542. A top cam lock 560 extends from the carriage540. The top cam lock 560 comprises a side-loaded opening 561 thatallows an elastic member to be side-loaded therein. In some embodiments,an elastic member can be extended through the bottom cam lock 530 andinto the top cam lock 560, whereby it can be further tensioned. The topcam lock 560 further comprises a release latch 562. Movement of therelease latch 562 releases the elastic member if desired, therebyreducing tension on the elastic member. In some embodiments, the top camlock 560 is spring loaded, such that upon release of the top cam lock560, the top cam lock 560 will go back to its original position andretain the elastic member therein. In addition, the carriage 540 of theupper member 504 comprises a counter torque attachment surface 570 whichcan be gripped by a counter torque device. The counter torque devicehelps to limit rotation to only those components necessary when rotatingthe tensioner driver. In some embodiments, the carriage 540 is capableof translation via the tensioner driver 550, thereby increasing thetension on the elastic member.

The tensioner driver 550 of the upper member 504 comprises a cylindricalmember that is attached to a proximal end of the carriage 540. In someembodiments, the tensioner driver 550 can comprise a base portion thatis received in a cut out portion of the carriage 540, thereby retainingthe tensioner driver 550 to the carriage 540. The tensioner driver 550includes internal threads that are configured to engage external threadsof the threaded shaft 580. Rotation of the tensioner driver 550 in afirst direction causes the tensioner driver 550 to rotate upwardly alongthe threaded shaft 580. As the tensioner driver 550 is attached to thecarriage 540, the carriage 540 also translates upwardly, therebyincreasing tension on the elastic member attached to the carriage 540.Rotation of the tensioner driver 550 in a second direction causes thetensioner driver 550 to rotate downwardly along the threaded shaft 580.This causes the carriage 540 to translate downwardly, thereby reducingtension on the elastic member attached to the carriage 540. In someembodiments, the tensioner driver 550 comprises a hex knob.

The threaded shaft 580 of the upper member 504 comprises externalthreads that engage internal threads of the tensioner driver 550. Insome embodiments, the threaded shaft 580 comprises a proximal cap 584.Advantageously, the proximal cap 584 serves as a stop that prevents thetensioner driver 550 from going past the cap, thereby reducing the riskof the tensioner driver 550 from falling off the threaded shaft 580.

The method of using the instrument 500 is as follows. In someembodiments, the lower member 502 is delivered to receive a clamp 10,which can further receive a rod member 80 therein. An elastic member orband that extends through the clamp 10 can be pulled through a sideopening or slot 531 of the bottom cam lock 530, thereby placing theelastic member in tension. The upper member 504 can then be deliveredinto attachment with the lower member 502, whereby it can be attachedvia a quick connection (e.g., a snap fit). The elastic member can thenbe pulled through a side opening or slot 561 of the top cam lock 560,whereby it can be retained in further tension. To increase tension onthe elastic member, the tensioner driver 550 can be rotated, therebycausing upward translation of the carriage 540 upon which the top camlock 560 resides. As the carriage 540 is drawn upwardly, this increasesthe tension on the elastic member. When the elastic member has achievedits desired tension, a set screw 25 (shown in FIG. 1A) can be downwardlythreaded onto the elastic member, thereby securing the clamp 10 to bone.The instrument 500 can then be removed from the clamp. First, the uppermember 504 can be released from the lower member 502 by pressing therelease button 544. Second, the lower member 502 can be released fromthe clamp 10 by pushing the sleeve release button 544 of the sleeve 520and drawing the sleeve 520 upwardly. This causes the fingers 512 toopen, which thereby allows the clamp 10 to disengage from the instrument500 if desired. In some embodiments, loose ends of the elastic membercan be cut while attached to the instrument 500. In other embodiments,loose ends of the elastic member are cut after detachment of theinstrument 500 from the elastic member. Any remaining loose ends of theelastic member can be glued, singed, or further cut if desired. At thistime, the clamp 10 is securely retained on a bone member.

FIG. 19 is a close-up view of a lower member of the integrated holderand tensioner instrument of FIG. 12. From this view, one can see theshaft 509, as well as the rounded flex cut 528 and elongated flex cut529 formed therein. The flex cuts 528, 529 advantageously help theinstrument to retain a clamp 10, simply by downward force onto the clamp10.

FIG. 20 is a side view of a lower member of the integrated holder andtensioner instrument of FIG. 18. From this view, one can see the fingers512 in a “open” configuration, whereby a rod member 80 can be receivedtherein. The fingers 512 include at least one hinged portion 513,whereby in the open configuration, the hinged portion 513 is away fromthe opposing finger, thereby providing room to receive the rod member80. To maintain the fingers 512 in the open configuration, the sleeve520 is pulled upwardly after pushing on the sleeve release button 517.

FIG. 21 a side perspective view of a lower member of the integratedholder and tensioner instrument of FIG. 18. From this view, one can seethe bottom cam lock 530 close up. The bottom cam lock 530 includes aside-loaded opening or slot 531 for easily delivering an elastic membertherein.

FIG. 22 is a perspective view of cam locks of the integrated holder andtensioner instrument of FIG. 18. From this view, one can see the bottomcam lock 530, the top cam lock 560 and the elastic member 60 thatextends between the two cam locks. Advantageously, the elastic member 60is side-loaded into each of the bottom cam lock 530 and the top cam lock560, thereby making it easier to retain the elastic member 60 therein.

It will be apparent to those skilled in the art that variousmodifications and variations can be made in the present inventionwithout departing from the scope or spirit of the invention. Moreover,the improved bone screw assemblies and related methods of use need notfeature all of the objects, advantages, features and aspects discussedabove. Thus, for example, those skilled in the art will recognize thatthe invention can be embodied or carried out in a manner that achievesor optimizes one advantage or a group of advantages as taught hereinwithout necessarily achieving other objects or advantages as may betaught or suggested herein. In addition, while a number of variations ofthe invention have been shown and described in detail, othermodifications and methods of use, which are within the scope of thisinvention, will be readily apparent to those of skill in the art basedupon this disclosure. It is contemplated that various combinations orsubcombinations of these specific features and aspects of embodimentsmay be made and still fall within the scope of the invention.Accordingly, it should be understood that various features and aspectsof the disclosed embodiments can be combined with or substituted for oneanother in order to form varying modes of the discussed bone screwassemblies. Thus, it is intended that the present invention cover themodifications and variations of this invention provided that they comewithin the scope of the appended claims or their equivalents.

What is claimed is:
 1. A surgical system comprising: an elastic member;a clamp for receiving the elastic member therein; and an instrumentconfigured to hold the clamp and tension the elastic member, wherein theinstrument comprises a lower member and a detachable upper member,wherein the lower member includes a sleeve configured to extend over ashaft, the lower member further configured to place fingers position ona distal end of the instrument in a closed configuration in a firstposition and in an open configuration in a second position, wherein thelower member of the instrument comprises a bottom cam lock having a sideslot for receiving the elastic member therein, and, wherein the uppermember comprises a top cam lock in line with the bottom cam lock forreceiving the elastic member therein.
 2. The system of claim 1, whereinthe clamp further comprises a first opening and a second opening,wherein a set screw is received in the first opening.
 3. The system ofclaim 2, wherein the elastic member is received in the second opening.4. The system of claim 1, wherein the clamp further comprises an inneropening formed by an inner curved wall of the clamp, wherein the innercurved wall includes a groove for receiving the elastic member.
 5. Thesystem of claim 1, wherein the instrument further comprises a carriageoperably attached to the tensioner driver.
 6. A surgical systemcomprising: an elastic member; a clamp for receiving the elastic membertherein; and an instrument configured to hold the clamp, wherein theinstrument comprises an upper member, a lower member, and a sleeve,wherein the upper member comprises a top cam lock having a side slot forreceiving the elastic member and the lower member comprises a bottom camlock having a side slot for receiving the elastic member therein,wherein the lower member has a sleeve release button that allows thesleeve to move along a longitudinal path over a shaft.
 7. The system ofclaim 6, wherein the clamp further comprises a set screw.
 8. The systemof claim 6, wherein the lower member of the instrument further comprisesa clamp holder having fingers for holding the clamp.
 9. The system ofclaim 6, wherein the instrument is configured to apply tension to theelongate member while holding the clamp.
 10. The system of claim 9,wherein the instrument comprises a tensioner driver for applying tensionto the elastic member.
 11. The system of claim 10, wherein the tensionerdriver is operably connected to a carriage, wherein the top cam lockextends from the carriage.
 12. The system of claim 6, wherein theinstrument further comprises a hex knob tensioner driver for increasingor decreasing tension on the elastic member.
 13. A surgical systemcomprising: an elastic member; a clamp for receiving a rod member andthe elastic member; and an instrument configured to hold the clamp,wherein the instrument comprises an upper member and a lower member,wherein the upper member is detachable from the lower member, whereinthe lower member comprises a bottom cam lock for receiving the elasticmember and the upper member comprises a top cam lock for receiving theelastic member, and wherein the lower member includes a sleeveconfigured to extend over a shaft, the lower member further configuredto place fingers position on a distal end of the instrument in a closedconfiguration in a first position and in an open configuration in asecond position.
 14. The system of claim 13, wherein the elastic memberis side-loaded into each of the bottom cam lock and the top cam lock.15. The system of claim 14, wherein the bottom cam lock comprises arelease latch.
 16. The system of claim 13, wherein the instrumentfurther comprises a tensioner driver and a carriage.
 17. The system ofclaim 16, wherein the top cam lock extends from the carriage, whereinrotation of the tensioner driver causes the carriage to translate suchthat tension increases on the elastic member.
 18. The system of claim17, wherein the tensioner driver is a hex knob tensioner driver.